A Seminal Study Asks: Should our paradigm for treatment be expanded? Are we doing enough?

The addiction treatment field and the larger alcohol and drug problems arena have historically drawn their knowledge from two sources: 1) the study of drugs and their personal, biological, and social precursors and consequences, and 2) the study of the clinical and social interventions designed to prevent, intervene in, or treat those consequences. These pathology and intervention paradigms are the foundation for policy, funding, research, and treatment in most of the world today. But is this enough? Are these paradigms offering the best opportunity to attain wellness? Is there a better paradigm? These were the questions that provoked the authors to conduct a study just published in the Alcoholism Treatment Quarterly (Volume 32, Issue 4, 2014) entitled: An Interpretive Phenomenological Analysis of Secular, Spiritual, and Religious Pathways of Long-Term Addiction Recovery.

The authors, each well steeped in recovery, research, and practice, set out on what became a two+ year journey to interview six individuals who attained and sustained recovery via diverse pathways. Through rigorous Interpretative Phenomenological Analysis (IPA) and a comparative computer analysis (ATLAS-ti), they found 64 shared themes and a number of critical unique tensions that varied in strength over three distinct stages of recovery. The six pathways to recovery studied were: Alcoholics Anonymous, Narcotics Anonymous, Secular Sobriety, Natural Recovery, Faith Based and Medication Assisted Recovery. The mean recovery time of the volunteer participants was 15.8 years.

Recovery Stage One (Pre-Recovery to Recovery Initiation) originated from the worst moments of hopelessness and despair, a heightened personal ambivalence about the drug life, external pressure, prior failed attempts at abstinence, and a new connection to a person(s) who could be trusted and who brought hope and understanding. The subjects all benefitted from the care of others, whether peer or professional, and the relationship that came with that care – even through continued struggles and failures. An understanding of addiction as a “medical illness” helped the subjects to understand themselves and to recognize the possibility of long-term recovery as shown by others whose lives offered proof of that possibility. Especially for the subject in medication-assisted recovery, being affirmed as being in recovery was completely transformational. Abstinence from the drug of choice, was common in all for recovery to begin and be sustained. To the surprise of the researchers, unique themes relating to culture (e.g., cultural roots or belonging), gender (e.g., trust) and one’s specific situation (e.g. medical need) arose as needing to be addressed and made relevant for “hope” and recovery to take hold.

Stage two (recovery initiation and stabilization) produced 23 shared themes. The first six-twelve+ months of care and recovery were supported by recognizing and working at attaining recovery, which reinforced the individual’s desire to change and to return to or begin a functional life. Early recovery was sustained amidst life challenges. Recovery-focused medical support, specialized addiction treatment, and medication all played supporting roles alongside increased family, friend, peer and other professional supports. Rejoining and noting improvements in relationships, quality of life and one’s self-narrative or belief in becoming a better person were pivotal. Reconstructing oneself as other than a person with an addiction (stigma “addict”), but as a person – and a person who is in recovery while healing – is critical in this stage.

The Third Stage (long term recovery maintenance) had the most shared themes – 24. In this phase, often begun at 2+ years in recovery, recovery begins to become assimilated into daily life. Attendance at recovery mutual-aid meetings may decrease, therapy may be diminished, but a new self emerges as recovery more consciously involves a larger purpose in life such as helping others or giving back to society while maintaining abstinence. In this stage, recovery is a way of being (“I am a person in recovery”)--living with a potentially devastating illness that no longer defines one and whose successful management allows one to be much more than that illness. After three years, relapse did not occur in any of the subjects.

This brief synopsis hopefully increases your interest in a study that offers much more for those interested in the emergence of recovery as an “organizing construct” for addressing addiction today. The authors were encouraged to find a rich international literature and growing numbers of studies on recovery as an emerging science. Our study reveals that recovery has an observable trajectory, shared themes, and an emerging common structure.

What does this mean for our science and our work? First, more study is needed about the “structure” of recovery via other recovery pathways and among specific populations seeking it (e.g. adolescents, veterans, LGBT, elderly): how and why is each step of recovery attained or not? A science of recovery, by shedding additional light on the components critical to attaining recovery, will inform existing policy, research, treatment and recovery support services. Such a science will illumine how we can improve clinical outcomes and enhance individual, family and community wellness. Implemented locally, a community understanding of recovery will strengthen prevention by assessing and strategically increasing each community’s recovery capital. An enhanced understanding of the lived experience of individuals in treatment and in recovery will also strengthen brief intervention and integrated care.

Some may express concern over basing a suggestion for paradigm change on a study with such a small “N” (number of subjects = 6), but that “N” is not unusual for rigorous qualitative study that pays carefully close attention to personal detail and nuance. Such a study of actual lived experience and how that experience begets personal change is a valid approach in the science of medicine. The authors invite and urge others to refine this work and expand that “N.”

We recognize that transcending the pathology paradigm will not be easy: it will require a new organizing philosophy of care, one that connects a broadened clinical understanding more thoroughly with lived experience. Our research and practice – prevention-intervention-treatment and recovery supports -- all need to be enhanced by the full realities of the illness. Addressing pathology will remain critical, but we must not stop there. As practitioners, persons in recovery, family members, community members, it is past time for us to ask, “Why do we do what we do?” The Recovery paradigm offers a new scientific perspective that deserves -- nay, begs for -- our attention.

To encourage dialogue all of the below authors have agreed to be respondents in this blog:

Michael Flaherty, Ph.D. is a clinical psychologist with over 35 years of practice and certification in the addictions and recovery. A former nine-year ATTC Director (Northeast ATTC), he currently focuses on clinical practice and assisting communities in building recovery supported models of care.

Ernest Kurtz, Ph.D., Adjunct Assistant Research Scientist, Department of Psychiatry, University of Michigan Medical School, has been a student of addictions and their healing since 1975.

William White, M.A., Emeritus Research Consultant at Chestnut Health Systems, has worked in the addictions field since 1969 in the arenas of outreach, counseling, clinical supervision, training and recovery research.

Ariel Larson, M.A. is a Ph. D. Candidate in Clinical Psychology at Duquesne University in Pittsburgh, Pa.

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The opinions expressed herein are the views of the authors and do not reflect the official position of the Department of Health and Human Services (DHHS), SAMHSA, CSAT or the ATTC Network. No official support or endorsement of DHHS, SAMHSA, or CSAT for the opinions of authors presented in this e-publication is intended or should be inferred.